VA Claims: Disabled Veterans Community|Hadit.com

Migraines Secondary to PTSD

VA Disability

I’m a Gulf War Veteran. Over the years my migraines headaches have gotten worse and I recently submitted a claim for migraines secondary to PTSD since Im rated at 70% SC for PTSD and 50% SC for sleep apnea. See my 2015 C&P exam for migraines below:
2015 Migraine C&P Exam
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
—————
Was the Veteran’s VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran’s VA claims file:
VBMS
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
————
Does the Veteran now have or has he/she ever been diagnosed with a headache
condition?
[X] Yes [ ] No
[X] Tension
ICD code: ICD-9-CM 307.81 Date of diagnosis: unknown
2. Medical History
——————
a. Describe the history (including onset and course) of the Veteran’s
headache conditions (brief summary):
He denies any specific head injuries that precipitated headaches. He
reports that he was diagnosed with headaches while on active duty. He
reports that his headaches are intermittent in nature. He has a
headache
about every other day that is rated a “6”. He takes Aleve for his
headaches. He denies having to leave work due to his headaches.
b. Does the Veteran’s treatment plan include taking medication for the
diagnosed condition?
[X] Yes [ ] No
If yes, describe treatment (list only those medications used for the
diagnosed condition):
He takes Aleve ii tabs by mouth as needed to get rid of his headache.
3. Symptoms
———–
a. Does the Veteran experience headache pain?
[X] Yes [ ] No
[X] Pulsating or throbbing head pain
[X] Pain localized to one side of the head
[X] Pain worsens with physical activity
b. Does the Veteran experience non-headache symptoms associated with
headaches? (including symptoms associated with an aura prior to headache
pain)
[X] Yes [ ] No
[X] Sensitivity to light
c. Indicate duration of typical head pain
[X] Less than 1 day
d. Indicate location of typical head pain
[X] Both sides of head
4. Prostrating attacks of headache pain
—————————————
a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating
attacks of migraine / non-migraine headache pain?
[ ] Yes [X] No
5. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms
—————————————————————————–
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
conditions
listed in the Diagnosis section above?
[ ] Yes [X] No
6. Diagnostic testing
———————
Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
7. Functional impact
——————–
Does the Veteran’s headache condition impact his or her ability to work?
[ ] Yes [X] No
8. Remarks, if any:
——————-
Medical Opinion; VBMS was reviewed and there was no mention on his exit paperwork that he had any problems with headaches. When the veteran came to the VA for treatment, in 2009, his PCP appt. put this statement about his headaches in the record, “NEURO-tension headaches , had CT scan of head in the County ER and it was negative. No migraine headaches. No seizures, no stroke.” The veterans current headache problems are diagnosable with a partially known etiology. This condition is less likely as not caused by or a result of his active duty service time in the Navy over 20 years ago.
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Since 2015 my headache severity and occurrences have almost tripled. I submitted a claim for migraines secondary to PTSD since Im rated at 70% SC for PTSD and 50% SC for sleep apnea. I submitted case notes from my PCP stating I have migraines along with prescription meds and dr. notes from non-va neurologist who diagnosed me as well and prescribed migraine meds. In January of this year, my VA dr. started prescribing me meds for my migraines as well since my insurance changed and visits to the neurologist were billed as out of network and was too high to pay out of pocket.
I submitted a lay of statement from my wife, a migraine diary with 6 months of records, and my neuro dr. notes that indicate that I missed almost 5 days per month out of the 15 scheduled days because of these headaches along with meds prescribed for my PTSD that has side effects that cause headaches.
Will this be enough to assist with establishing my claim? My claim has been in PFD for over 45 days and have exceeded the estimated time of completion twice and no C&P exam has been scheduled or pending. Any comments?

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